Social Work Care Manager II

Job Summary

Responsible for partnering with members of the health care team to assess needs, coordinate services, and implement care plans that support safe, effective, and cost-conscious care delivery. Connects members with appropriate clinical, behavioral health, and community resources; monitors progress toward care goals; and assists with care transitions and discharge planning. Supports members in maximizing independence, addressing psychosocial needs, and improving overall health and quality of life.

Essential Responsibilities

• In close collaboration with the member/members family, and members of the health care team, assesses the members health status, functional limitations, psychological status, social support systems, resources, environmental factors, and response to treatment.
• Uses motivational interviewing techniques to identify members readiness for change, creates appropriate care plan based on assessments, assists member with health system navigation and connection to community resources.
• Provides supportive counseling and education to members, families and caregivers, members of the health care team, and others including end-of-life issues and Advance Directives.
• Effectively manages and coordinates assigned caseload consistent with established criteria. Ensures consistent and reliable documentation of case management activities in compliance with all organization and department standards.
• Facilitates application process for accessing local, state, and federally funded programs (e.g., Medicaid, Medicare, Disability) and/or refers to appropriate community resources.
• Coordinates care across the care continuum for members receiving behavioral health and substance abuse services.
• Responsibilities include, but are not limited to, problem identification, psychosocial assessment, financial counseling/referral, accessing community resources, placement for care, guiding the member through health-related legal processes, or consultation and support to other health care professionals.